Healthcare Provider Details

I. General information

NPI: 1992858450
Provider Name (Legal Business Name): EYE CARE & SURGERY ASSOC., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 MICHIGAN ST WILSON MEDICAL BUILDING STE 101
SIDNEY OH
45365-2401
US

IV. Provider business mailing address

915 MICHIGAN ST WILSON MEDICAL BUILDING STE 101
SIDNEY OH
45365-2401
US

V. Phone/Fax

Practice location:
  • Phone: 937-492-8040
  • Fax: 937-492-7447
Mailing address:
  • Phone: 937-492-8040
  • Fax: 937-492-7447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number34003529W
License Number StateOH

VIII. Authorized Official

Name: DR. JOHN J WILDING
Title or Position: PRESIDENT
Credential: D.O.
Phone: 937-492-8040